Patients presenting
with epistaxis are anxious and fear bleeding to death. Although death from
epistaxis is rare, it can occur, and significant morbidity is relatively
common. [5][34] Although most pediatric epistaxis is treated
on an outpatient basis, older patients (>60 years old) more often require
hospital admission. [25][44] Initial management of
epistaxis is directed at stopping the bleeding, and long-term treatment is
directed at discovering and correcting the underlying cause. This article
updates current management options.

ANATOMIC CONSIDERATIONS IN EPISTAXIS

The blood supply to the nose arises from the internal
maxillary and facial arteries via the external carotid and the anterior and
posterior ethmoid arteries via the internal carotid artery. The anteroinferior
septum (Little's area) is supplied by a confluence of both systems
(Kisselbach's plexus). Little's area is a common site of epistaxis because it
is ideally placed to receive environmental irritation (cold, dry air, cigarette
smoke) and is easily accessible to digital trauma. This area is easy to access
and treat. Bleeding arising further within the nasal cavity can be difficult to
reach. Surgical ligation of the contributing arteries can be challenging because
of their deep location and complex anatomy.

PATHOPHYSIOLOGY

Much epistaxis ceases with pressure (digital or packing)
over the bleeding point. An intact coagulation system with accumulation of
platelets and clot formation is required. Abnormal platelet numbers or function
or any abnormality in the coagulation cascade leads to failure of clot
formation and persistent bleeding.

Cold, dry air increases cases of epistaxis. In countries
with seasonal climates, hospital admissions for epistaxis increase during the
winter months. [24][44][61] Patients were
admitted at a rate of 0.829 patients per day for temperatures less than 5°C
compared with 0.645 patients per day for temperatures between 5.1°C and 10°C. [61]
Most had some form of dry air heating, without humidification, in their homes.

Nasal ciliary activity decreases as temperature drops.
Normal ciliary activity (at 32°C to 40°C) occurs at about 15 Hz frequency,
dropping to less than 5 Hz below 20°C. [16] Although extremely dry
air is known to promote epistaxis, the exact humidification as a preventive
measure remains undefined. Temperatures of above 52°C have been associated with
cellular damage. [56]

Local Factors

Trauma

Nose picking and accidental injury are the commonest
traumatic causes of epistaxis. Except with severe facial trauma, such as motor
vehicle accidents, this epistaxis is usually from an anterior nasal source and
easily treated. [18]

Nasal Septal Deviation

Nasal septal deviation is common, but its role in epistaxis
is not certain. In one study, 16% of patients with severe refractory epistaxis
had marked septal deviation. [23] In another study of patients with
recurrent epistaxis, 81% had septal deviation versus 31% in the control group. [46]
The epistaxis group also had a higher incidence of radiologically demonstrated
septal deviation compared with the control group (62% versus 37% [P<.02]). The bleeding tended to occur
from the side to which the septum was deviated. Exactly how a septal deviation
could cause bleeding is not clearly established. Because septal deviations do
cause nasal obstruction turbulent air flow, this may cause abnormal mucosal
drying, making the mucosa more susceptible to bleeding.

Iatrogenic

Septal, turbinate, nasal, sinus, or orbital surgery can be
followed by epistaxis. Blood-stained nasal discharge is common in the initial
week or two after surgery. Severe epistaxis can occur, especially after partial
turbinate resection (0.9% to 8.9%). [14] Management of such patients
is aimed at controlling the bleeding and contacting the surgeon to provide
appropriate follow-up.

Inflammation
(Infection and Allergy)

Epistaxis can result from nasal lining inflammation, with
acute respiratory infections, chronic sinusitis, or allergic rhinosinusitis. In
children and the mentally disabled, intranasal foreign bodies cause unilateral
foul-smelling discharge that can be accompanied by epistaxis. Children with
both nasal allergy symptoms and positive skin tests have more frequent
epistaxis (20.2%) than those with symptoms alone (9.9%), positive skin test
alone (3.4%), or neither symptoms nor positive skin test (2.1%). This study
suggests that allergic rhinitis predisposes to epistaxis, either by mucosal
irritation or possibly by the atopic state contributing to a hemostasis
disorder. [43]

Tumors

Epistaxis can be the only symptom in patients with a nasal
tumor. In adolescents, the most serious cause of recurrent epistaxis is the
intranasal tumor, juvenile angiofibroma. Other neoplastic causes of pediatric
epistaxis include papillomas, polyps, and meningoceles or encephaloceles
(infants). [8] In adults, almost any benign or malignant intranasal
tumor can present with epistaxis. Intranasal lesions can sometimes be seen by
looking in the nose with the otoscopic ear piece. Biopsy of intranasal lesions
is approached with caution because biopsy of highly vascular lesions, such as a
juvenile angiofibroma, can cause significant blood loss and morbidity.

Although hypertension is often cited as a cause of
epistaxis, several large studies have shown no higher rate of underlying
hypertension among epistaxis patients than in patients without epistaxis. [41][67] Hypertension patients taking diuretic or methyldopa medications
may have more epistaxis than those taking beta-blockers (60%). [9]
Hypertension at the time of epistaxis treatment may be anxiety related,
returning to normal on control of the epistaxis and reassurance. [23]
Epistaxis patients with hypertension must be followed after control of the bleeding,
to ensure that blood pressure returns to normal on control of epistaxis because
some are found to have underlying hypertension requiring ongoing treatment.

Renal Disease

Persistent epistaxis may be encountered in chronic renal
failure patients undergoing hemodialysis, but the true incidence remains
unknown. [64] Contributing causative factors may include elevated
prostacyclin levels (platelet antiaggregatory activity) [40] and
prolonged use of low-molecular-weight heparin. [54] An 8% incidence
of septal perforations has been noted in renal failure patients. Localized
irritation caused by turbulent air flow around the perforation could also
contribute to epistaxis in these patients. [1]

Alcohol

Heavy alcohol consumption increases the risk of epistaxis.
The same platelet reactivity inhibition that provides a protective effect for
the coronary arteries may also increase bleeding time, making epistaxis more
difficult to control. [37][50] Bleeding risk, however,
was not linearly related to alcohol consumption, with those consuming 1 to 10
alcoholic drinks per week most affected and those drinking more than 10 drinks
per week less affected. Rebound of platelet activity may explain this finding,
but the mechanics have yet to be elucidated. The use of NSAIDs did not confer
an additional risk of increased bleeding time. [50]

Coagulation and
Vascular Abnormalities

Patients with hereditary conditions, such as hemophilia, von
Willebrand's disease, and thrombocytopenia, frequently experience epistaxis.
Thrombocytopenia can also occur with hematologic malignancy, chemotherapy, or
viral infections, such as dengue hemorrhagic fever [21] and human
immunodeficiency virus (HIV), [15] or can be idiopathic.

Hereditary hemorrhagic telangiectasia patients are particularly
prone to epistaxis problems. [17] The abnormal vessel walls and
focal endothelial degeneration contribute to refractory epistaxis, which can be
challenging to manage. Treatment is aimed at decreasing the frequency of bleeds
and need for transfusion because permanent cure is not possible.

Medications

Numerous medications interfere with normal clotting. NSAIDs
(including aspirin) are probably the most common, with up to 75% of epistaxis
patients using one of these medications. [36] One study found that
42% of epistaxis patients were taking warfarin, dipyridamole, or NSAIDs versus
3% of the nonepistaxis control group. [66] These medications
interfere with the cyclooxygenase pathway in arachidonic acid metabolism,
inhibiting platelet aggregation. [33] One author suggested that a
history of epistaxis may be a relative contraindication to the use of NSAIDs. [66]
In addition, because 74% of aspirin use is self-administered, the public needs
to be made aware of the relationship between aspirin and nosebleeds as
potential side effects. [2]

Other medications associated with epistaxis include
thioridazine, topical hyperosmolar sodium chloride, and dipyridamole
(Persantine). Epistaxis resolving when the drug is stopped has occurred with
thioridazine. The nasal mucosal drying from the anticholinergic effects of this
low-potency phenothiazine, coupled with home heating in the dry winter season
in hypertensive patients was thought to be the underlying cause of epistaxis. [22]
Dipyridamole inhibits adenosine diphosphate and collagen-induced platelet
aggregration, enhancing disaggregation and prolonging bleeding time. [42]
Epistaxis has also occurred in a patient using hyperosmolar sodium chloride
(2%) eye drops. [29] The patient developed dry nasal mucosa,
presumably from osmosis, when the eye drops arrived in the nasal cavity via the
nasolacrimal duct. The problem resolved when sodium chloride ointment was
substituted for the drops. Use of steroid nasal sprays can also be complicated
by epistaxis, which is usually mild and stops after cessation of use of spray. [24]

MANAGEMENT

There are three levels of epistaxis management: (1)
first-aid measures, (2) acute management, and (3) interventions.

First-Aid Measures

In one series of patients taking systemic anticoagulants, 25%
had experienced epistaxis in the previous year. Less than half of the patients [31]
could think of a single first-aid measure to stop nosebleeds. Clearly,
additional education in this at-risk population could reduce both morbidity and
patient anxiety.

First-aid measures include the following:

Digital compression. Although so simple as to seem
reflexic, fewer than 50% of emergency department personnel could describe
the correct site to apply digital pressure in a nosebleed (Fig. 1) . [38] A swimmer's clip has also been
used for epistaxis. [62]

Cotton or tissue plug in the nose. Patients often
arrive in the office with a piece of tissue pushed into the nostril that
has been bleeding.

Bending forward at the waist. This position allows
gravity to keep blood flowing out the nostrils, rather than posteriorly
down the throat. [9]

Spitting out any blood that trickles down the back of
the throat. The patient is prevented from swallowing large amounts of
blood.

Cold compress on nasal bridge. This practice has a
vasoconstrictive effect. [35]

Acute Management

Hypotension associated with epistaxis can precipitate acute
myocardial events or aspiration, sometimes leading to death. The patient with
an actively bleeding nose is apprehensive and often has reactive hypertension,
accentuating the bleeding. The basics of airway, breathing, and circulation
remain key principles. Securing the airway via endotracheal intubation or
trachesotomy in the severely injured unconscious patient allows suctioning and
packing of the nose and, if necessary, the oral cavity and pharynx. Oxygen
ensures good systemic oxygenation, especially important in patients with
underlying cardiopulmonary disease. Intravenous access is established in all
patients presenting with active epistaxis because significant bleeding has
usually occurred before the patient seeks medical attention. When inserting the
intravenous line, it is usually convenient to obtain blood for complete blood
count and, if clinically indicated, type and screen, coagulation profile, and
electrolytes (in anticipation of surgical intervention).

An assessment of the amount of blood lost is made from the
history, including the onset of the bleeding, precipitating factors, duration
and quantity (i.e., number of soaked towels), past history of epistaxis and
treatment, and history of blood dyscrasias. In adults, a history of medication
(including NSAIDs, anticoagulants), hypertension, ischemic heart disease,
diabetes mellitus, and alcohol abuse may influence management. In children, a
history of epistaxis with unilateral nasal discharge alerts the physician to
the possibility of an intranasal foreign body. Consent for blood transfusion is
recommended. The vital statistics (blood pressure and pulse) of the patient
should be charted.

The patient is supplied with folded gauze 4 × 4 pads to soak
up blood trickling from the nose. A chart is started to keep track of the
number of pads required, as further assessment of the amount of blood lost.

Local Compression

Thumb and index finger nasal compression pressure is used as
the first measure by the physician while other treatments are being instituted.
Local finger compression should be employed for at least 5 minutes to allow
formation of a hemostatic plug over the bleeding vessel.

Cauterization

Most epistaxis originates in the anterior nasal cavity,
often in Little's area. Effective local vasoconstrictive measures include
pseudoephrine (Afrin), phenylephrine (Neo-Synephrine), or epinephrine
(1:10,000) applied to the area on cotton pledget.

The area of bleeding can be cauterized. Silver nitrate is
the most convenient cauterization agent, available in ready-made sticks. Local
anesthesia with 4% lidocaine solution (applied by cotton pledget for 5 minutes)
can reduce the stinging of cautery. Accurate identification of the bleeding
points and a good light for intranasal examination are the keys to successful
cauterization. The temptation to cauterize a large area of the septum to cover all bleeding points should be
resisted. The authors routinely use a cotton-tipped applicator to mop up residual silver nitrate after
application, to prevent local damage to the underlying perichondrium.
Postcautery, antibiotic cream or ointment is applied to the cauterized area
twice a day for 5 days to prevent crusting and infection. Both sides of the
septum should not be cauterized at the same time because of the risk of septal
perforation. Repeated cauterization in the same area can also lead to septal
perforations.

Oxymetazoline hydrochloride (an imidazole derivative)
is a topical vasoconstrictor commonly used as a nasal decongestant. [28]
Of 60 patients coming to an emergency department with epistaxis, there was
a 65% success rate with oxymetazoline alone. A further 18% of patients
required silver nitrate cautery, and the remaining 17% required nasal
packing.

Cryotherapy. This procedure for applying cold
temperatures within the nose to control epistaxis reportedly has less
morbidity than other local methods. [20] It requires a machine
capable of delivering the necessary temperature to freeze the target
tissues.

Hot-water irrigation. Success in treatment of
epistaxis has been reported, although patient compliance is variable. [56]

Laser therapy, diathermy, septodermoplasty, and other
surgery. Surgery has been advocated for hereditary hemorrhagic
telangiectasia with variable success. [10][49][63]

Anterior Nasal Packing

Packing is needed when local measures are unsuccessful in
controlling epistaxis. Nasal packing is an uncomfortable procedure and can have
life-threatening complications, anterior packing less so than combined
anterior-posterior packing. Classic anterior packing is performed with
Vaseline-impregnated narrow gauze, placed in the nose until sufficient pressure
exists to tamponade the bleeding. Although the tidy textbook diagrams of
layered packing are somewhat misleading, the general goal is to place the
packing from the back and bottom of the nose forward. A training model for
nasal packing has been reported to improve confidence and competence in the
procedure. [59]

Other options for anterior nasal packing include synthetic
sponge packs (tampons) such as Merocel that expand when moistened or balloon
packing. Merocel packs are easy and quick to insert and can be used for
bilateral epistaxis as well. The success rate of such packing exceeds 90%, even
when performed by inexperienced physicians. [48] Both nasal tampons
and gauze packing are efficacious and well tolerated. [7]

After anterior packing, the oropharynx is inspected. If
blood is still visible trickling from the nasopharynx, either the anterior pack
is suboptimally placed, or there is a posterior nasal bleeding source. The
nasal cavity measures about 7 cm from columella to nasopharynx, so the most
common error in anterior nasal packing is failure to pack adequately the
posterior aspects of the anterior nasal cavity.

Adequate lighting and long forceps (bayonet or Tilley's
nasal packing forceps) are necessary for placement of an effective anterior
gauze pack. Gauze coated with BIPP (bismuth iodoform paraffin paste) can be
left in the nasal cavity for up to a week with low risk of infection. Vaseline
gauze packing is usually removed by 72 hours. Antibiotic prophylaxis is usually
administered.

Elderly or frail patients with anterior nasal packing and
most patients with posterior nasal packing should be hospitalized for oxygen
supplementation, intravenous hydration, bed rest, and mild sedation. Because
bilateral nasal packing obstructs the nose and prevents nasal breathing, it
often causes hypo-oxygenation. Anterior-posterior nasal packing with sedation
is accompanied by decreased arterial oxygen tension and altered pulmonary
mechanics. [5] Oxygen is usually administered via face mask with
anterior and posterior packing (unless the carbon dioxide is elevated).
Sedation is carefully titrated, keeping in mind the patient's cardiopulmonary
status.

Other materials used for nasal packing include Kaltostat,
Ativene, and porcine fat (salt pork). A randomized trial comparing Kaltostat
and bismuth tribromophenate (Xeroform) showed similar efficacy and patient
acceptance. [39] Ativene successfully controlled 77% of idiopathic
anterior epistaxis and can be useful in hereditary telangiectasia epistaxis. [60]
Salt pork has been used for nasal packing in patients with thrombocytopenia,
commonly secondary to renal failure or medications. Homogenates of salt pork contain
an aqueous factor that serves as a platelet substitute, inducing platelet
aggregation and enhancing adenosine diphosphate and collagen-induced
aggregation. The pork fat is less irritating to the mucosa on removal than
gauze packs. [4] This material is not used in patients who avoid
pork for religious reasons.

Posterior Nasal
Packing

Only about 5% of epistaxis originates from a posterior nasal
source. [64] The posterior nasal space is cylinder shaped, opening
anteriorly into the nasal cavity and posteriorly into the nasopharynx. Packing
in this space tends to fall back and down, into the oropharynx. To pack the
posterior nasal cavity, a conforming pack is first placed in the nasopharynx,
secured anteriorly near the nostrils. Gauze or other anterior packing can then
be firmly placed against this resistance.

Classically a posterior pack is made of rolled gauze secured
with umbilical tape, although balloon packs are sometimes used (Foley catheter,
Brighton Balloon, Simpson Balloon). Posterior pack insertion begins with
passing a rubber catheter through each nostril, into the oropharynx. They are
grasped here and brought out anteriorly through the mouth. Long ties attached
to each side of the gauze pack are attached to the catheters, and the catheters
are gently withdrawn through the nose, leaving a gauze pack held in the
physician's hand, with the attached long ties entering the mouth and exiting
both nostrils. With gentle traction on the nostril ends, the pack is pulled and
pushed into the oropharynx, then tucked up into the nasopharynx. The mouth ends
of the ties are left long, to be grasped later and used in pack removal. The
nostril ends are secured anteriorly, usually around the columella. Care is
taken to pad and protect the columella from excessive pressure that could cause
ischemic necrosis. This unpleasant procedure can be performed under mild
sedation, but use of general anesthesia when possible is a kindness to the
patient. Posterior packs are usually left in place for 48 to 72 hours because earlier
removal is associated with an increased risk of rebleeding.

An alternative to posterior packing with gauze is balloon
catheters inserted in the nasopharynx via the nostrils and inflated with
sterile water. The balloons are secured anteriorly using a clamp (e.g.,
umbilical cord clamp). Either Foley catheters or balloons designed specifically
for the nasopharynx can be used. The balloons have a tendency to deflate with
time, and volume can drop by 30% or more in 72 hours. [45]
The authors usually deflate the balloons at 48 hours and remove both anterior
and posterior packings at 72 hours.

Complications of Nasal
Packing

Nasal packing can be complicated by death. [5]
Aspiration of blood, cardiopulmonary failure secondary to hypoxia, and toxic
shock syndrome have led to mortality in patients with epistaxis. Complications
in nasal packing include

Nasal trauma from the packing.

Nasal-vagal response (bradycardia, hypotension,
apnea).

Dislodged packing.

Aspiration.

Persistent bleeding.

Infection, toxic shock syndrome.

Hypoxia resulting from nasal obstruction--may result
in myocardial infarction, disorientation.

Most complications can be avoided if anticipated. Firm and
gentle packing avoids excessive nasal mucosal trauma. Sedation is kept to the
minimum necessary to decrease aspiration risk and respiratory suppression.
Oxygen should be given when there are no contraindications. All patients
receive prophylactic antibiotics.

Toxic shock syndrome occurring with nasal packing can cause
significant morbidity and mortality. More than one third of patients undergoing
nasal packing are Staphylococcus aureus
carriers. Comparison of NuGauze packs to Merocel packs removed from patients'
noses revealed NuGauze grew out
substantially more S. aureus. [3]
This may occur because Merocel is a single homogeneous structure, whereas
NuGauze packing has interstices and folds of varying sizes that more readily
pool secretions. Toxic shock syndrome begins with fever, vomiting, diarrhea,
hypotension, and body rash secondary to the production of TSST-1, the primary
toxin causing toxic shock syndrome. S.
aureus is often sensitive to bacitracin, so use of this intranasally can
help prevent toxic shock syndrome. Oxytetracycline and polymyxin B can also decrease
the number of bacterial strains cultured from packing used for nasal packs. [19]

Interventions

Surgery

Endoscopic Cauterization.

Endoscopes have revolutionized sinonasal surgery over the
past two decades. In the management of epistaxis, use of the endoscope can
permit identification of posterior bleeding sites, which can then be directly
cauterized, avoiding packing. [12][51] It is especially
useful in patients who continue to bleed through well-placed nasal packs.

For these patients, the packings are usually removed when
the patient is under general anesthesia. The nasal cavity is cleansed and
endoscopically examined. Common bleeding sites include the region of
distribution of the sphenopalatine artery, posterior end of inferior turbinate,
posterior-inferior septum, and anterior sphenoid face. The suction
electrocautery is useful. In the rare cases in which no bleeding sites are
located, Merocel packs are placed for 48 hours.

The authors have been using endoscopic examination in the
outpatient setting with selected patients. Using good topical anesthesia and
mild sedation and a suction/electrocautery unit, some more posteriorly placed
bleeding points can be identified and cauterized with minimal patient
discomfort. Many of these patients would traditionally have required nasal
packing and hospitalization, so avoidance of this is popular with both patients
and managed care companies.

Arterial Ligation.

Arterial ligation decreases arterial blood flow to the
bleeding area. Commonly ligated supplying branches include the internal
maxillary artery (terminating as the sphenopalatine artery) and the anterior
ethmoidal artery. Ligation of the external carotid artery is also possible,
although uncommonly needed.

Posterior epistaxis is usually supplied by the terminal
branches of the internal maxillary artery. The third part of the internal
maxillary artery courses behind the maxillary antrum to the sphenopalatine
foramen at the superomedial sinus. As the internal maxillary artery exits the
sphenopalative foramen, it divides into medial (to the sphenoid/septum) and
lateral (lateral nasal wall) divisions. The transantral (via the maxillary
antrum) approach allows ligation just before the terminal branching.
Traditionally the transantral approach involved the removal of anterior wall of
the maxillary sinus (Caldwell Luc) for surgical access. [6] The
microscope is used for dissection behind the posterior wall of the antrum. The
endoscope has provided an alternative approach with less morbidity, although it
is technically more difficult.

Ethmoidal arterial ligation is performed when bleeding
arises in the superior nose (above the middle turbinate). Ethmoidal artery
ligation uses a curved incision around the medial canthus. The globe is
retracted away from the lamina papyracea, and the anterior ethmoidal artery is
encountered about 24 mm from the anterior lacrimal crest. The vessels are
clipped and ligated under direct vision. Patients with intractable epistaxis
without an identifiable bleeding point may benefit from ligation of both the
anterior ethmoidal artery and the internal maxillary artery.

Embolization.

An alternative to surgical ligation is embolization of
external carotid artery branches. [11][26][58]
This procedure is particularly useful in patients at high risk for a general
anesthetic or with unfavorable anatomy (small maxillary antra). [47]
Embolization is successful in up to 96% of cases, although vascular anatomic
variations limit application in some cases. One benefit of embolization over
arterial ligation is that more selective blockade of smaller branches is
possible.

Complications of embolization include up to 6% of neurologic
sequelae. The risk of particulate material embolization to the internal carotid
systems has been minimized by the current use of microcoils. [13]

Blood Transfusion

With the risk of disease transmission through blood products
increasing, epistaxis is treated to minimize the need for transfusion. Nasal
packing has been the first-line treatment of patients whose bleeding cannot be
managed on an outpatient basis. Packing provides a tamponade and encourages
thrombosis of vessels. There have been signs of this shifting toward early and
prophylactic intervention. [52] One study compared the cost of hospitalization
with nasal packing to hospitalization with surgical intervention and reported a
higher cost and complication rate with surgical intervention. These patients,
however, received surgical intervention only after failing nasal packing. There
was a 27% transfusion rate (3 units per patient) with nasal packing compared
with 41% (5.8 units per patient) with nasal packing failure and subsequent
surgery. Another study also noted a greater transfusion requirement with
surgical intervention than without (0.91 units versus 2.93 units, P<.01). [53] These authors
suggest that patients requiring more than 3 units of blood should be considered
for surgical intervention. The cost and risk of surgical intervention must be
weighed against the risks of transfusion and compromised cardiovascular status
if rebleeding occurs.

Dealing with a patient with active severe epistaxis can be
bloody. The authors recommend universal precautions for all health care
personnel involved in the care of these patients, including face mask with
shields, gowns, hair coverage, and double-gloving.

SUMMARY

Epistaxis is a common clinical problem. The widespread
availability of endoscopic equipment is shifting management philosophy toward
targeting the bleeding point. This shift may have a significant impact on
decreasing length of stay and blood transfusion rates. Advances in
interventional radiology have also reduced the risk of embolization. Patient
education, especially teaching first-aid measures to patients at high risk for
nosebleeds, also encourages more effective use of health care resources.

ACKNOWLEDGMENTS

The authors thank Carol Chan for her assistance with the
illustrations.